Study: Seniors who scrimp on doctor visits now pay more later

Rising health-care costs have led many Americans to put off going to the doctor. But a new study confirms what many have suspected: Postponing care means greater costs in the long run,particularly for seniors.

The study, appearing today in the New England Journal of Medicine, showed that many seniors avoided important outpatient care after their Medicare copayments increased. The result: more hospital admissions and longer hospital stays.

The findings are consistent with previous studies on the health care habits of the general population and the poor.

But especially during the current economic downturn, health experts and advocates for the elderly say seniors are particularly vulnerable. They are more likely to have fixed incomes and to rely on market-vulnerable investment income.

"They only have so much money to live on. If their copayments are going up, and they have a chronic condition, there's only so many visits they may be able to afford," said Mary Johnson, a policy analyst for the Senior Citizens League, a nonprofit advocacy group.

Another factor: the increased popularity of Medicare Advantage plans, which are run by private companies and offer perks such as cash back and free gym memberships, but also often require copayments for doctor visits.

The study, conducted by researchers at Brown University and Providence (Rhode Island) VA Medical Center, involved nearly 900,000 Medicaid beneficiaries enrolled in 36 Medicare managed-care plans from 2001 through 2006. In half of the plans, mean copayments for ambulatory care increased for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). Copayments in the other 18 Medicare plans were unchanged over the study period ($8.33 for primary care; $11.38 for specialty care).

Researchers found that in the year after the increase in copayments, beneficiaries in those plans had 19.8 fewer outpatient visits per 100 enrollees, but 2.2 more hospital admissions and 13.4 more inpatient days per 100 enrollees than those in plans where copayments stayed the same.

Rising costs have forced many public and private insurers to shift more of those costs to patients. Copayments and deductibles for many employer-based and Medicaid plans have also increased over time.

And while just 0.3 percent of Medicare enrollees had plans requiring a copayment of more than $15 for a primary care visit in 1999, that jumped to 24 percent by 2003.

Jay Wolfson, a public health and medicine professor at the University of South Florida, explained that there was a good reason to impose copayments and other out-of-pocket costs, starting back in the 1960s.

"There was a reasonable expectation that if you erected a modest financial barrier, it would deter unnecessary utilization — such as people who would go to the doctor whenever they had an itch," Wolfson said.

By the 1990s and beyond, copayments, deductibles and other cost-sharing became standard on most health plans.

But the reasoning behind them may be faulty, study authors note.

"Increasing the patient's share of the cost … may not reduce (or may even increase) total health care spending and may result in worse health outcomes," the study said.

Advocates say that while seniors should recognize that putting off care now can lead to more problems in the long run, they understand that many can do nothing about it.

"They have to respond to pocketbook issues," said Cheryl Matheis, a senior vice president for health strategy with the AARP.

The sagging economy has only made things worse, affecting many seniors' nest eggs, she said.

Matheis and Johnson said seniors need to know the Medicare options available to them. Though many are lured by Medicare Advantage plans that offer zero premiums and other benefits, many plans require copayments that can increase over time.